Clinical Care Manager

Schedule : Monday-Friday 8am-4pm

Salary : $90,000 annually

The Clinical Care Manager (CCM) provides intensive care coordination and clinical care management for MassHealth Members with complex medical and behavioral health needs who are enrolled in an Accountable Care Organization (ACO) or Managed Care Organization (MCO) plan. The CCM collaborates with their respective Community Partner team and the clinical staff of each Enrollee’s ACO / MCO’s plan to minimize duplicative efforts, promote integrated care, ensure quality and continuity of care, and support the values of person-centered planning, Community First and SAMHSA Recovery Principles. The CCM is at the helm of organizing and coordinating resources and services in response to the Enrollee’s healthcare needs across multiple settings, and inclusive of both LTSS and Social Determinants of Health (SDH) needs. This role drives outreach and engagement, assessment and care planning, care transitions, health and wellness coaching, as well as community and social services connections in partnership with Enrollees and their care teams.

Responsibilities :

• Outreach to and engage enrollees enrolled in ACO and referred for CP program.
• Conduct comprehensive assessment of enrollees including the medical, psychiatric and social issues of enrollees served.
• Review / sign off on medical component of comp assessment of Care Team enrollees.
• Organize and facilitate the effective functioning of the Interdisciplinary Care Team (ICT), including coordinating meetings, facilitating communication, and documentation.
• Monitor the enrollee’s health status and needs and provide nursing and medical care coordination, including revising health related treatment goals and plans in collaboration with the enrollee and the team.
• Coordinate the development, implementation, monitoring, and review of the enrollee care plans, including health care strategies.
• Collaborate closely with PCP and other Providers including, but not limited to community resources, and assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
• Collaborate with ACO Plan, PCP, and other health care Providers regarding changes in services,

care transitions, crisis intervention; while focusing on continuity and quality of enrollee care and potential efficiencies and cost-savings.

Qualifications :

Typical Requirements :

Minimum of 5 years clinical and case management experienced preferred. Effective skills in managing,

teaching, negotiating, and collaborating with multidisciplinary teams and enrollee / family focus.

Experience working with people with psychiatric disability, co-occurring disorders preferred. Preference

given to bi-lingual / bi-cultural applicants and applicants with lived experience of psychiatric conditions.

Preferred / Required Education :

BSN or MSN required

Driving Requirements :

Driving is a requirement for this position using either a Vinfen van or personal vehicle. - If using a personal vehicle, you must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks. A valid driver's license must be presented at the time of employment. Incumbents must be at least 21 years of age, have maintained a valid US driver's license for at least six months, and must be able to pass a driver's screening background check.

Knowledge and Skills :